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MEDSTAR PHARMACY STORE # 12
DSH090004 Georgetown University Hospital
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Covered Entity Details
Entity Name
Georgetown University Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH090004
Entity Address
3800 Reservoir Road, NW
Washington, DC 20007
Medicare Provider Number
090004
Participating Start Date
4/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MEDSTAR PHARMACY STORE # 12
Pharmacy Address
9000 FRANKLIN SQUARE DR
ROSEDALE, MD 21237-3901
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/7/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David C Ho, VP of Finance
(202) 444-4724
Contract Pharmacy Representative
MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773
Signed By Date
4/13/2020
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